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La stenosi valvolare aortica nellanziano: diagnostica ecocardiografica Maurizio Baroni Bologna

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The Euro Heart Survey on Valvular Heart disease Iung B, EHJ (2003); 24:1231-1243 3-4 % popolazione sopra 75 anni

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The Euro Heart Survey on Valvular Heart disease Eziologia della stenosi valvolare aortica Iung B, EHJ (2003); 24:1231-1243

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Otto C. NEJM 2008; 359:1395-98 Histopathological features of human aortic valves removed at surgery or necropsy were the first to support the hypothesis that aortic valve stenosis is the result of an active inflammatory cellular process characterized by lipoprotein deposition and molecular mediators of calcification. Natural history of valve

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Storia naturale della stenosi valvolare aortica a seconda della severit nell anziano Iivanainen, Am J Cardiol 1996 476 patients 75-86 y.o. 412 no AS (2.1 cm2) 25 mild AS (1.2 cm2) 26 moderate (0.9 cm2) 13 severe AS (0.6 cm2) 4-year follow-up

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Survival of asymptomatic patients with severe aortic stenosis versus age-matched US population Pellikka PA, Circulation 2005; 111: 329095

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Survival of patients with aortic stenosis over time

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Mean survival of patients with symptoms of AS Schwarz F,. Circulation 1982; 66: 110510.

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VALVULOPLASTICA AO TECNICA VALVULOPLASTICA AORTICA

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Stenosi aortica calcifica Valvuloplastica percutanea Valvuloplastica percutanea * PONTE ALLA CHIRURGIA: -AREA VALVOLARE

Guideline criteria for severe aortic stenosis ACC/AHAESC Aortic valve area (AVA) 50 mmHg Maximum aortic jet velocity > 4 m/sec

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Equazione di Bernoulli (semplificata) Gradiente pressorio = 4 V2 GRADIENTE PRESSORIO Equazione di Bernoulli

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GRADIENTE TRANSVALVOLARE MEDIO Calcolato automaticamente dalle macchine Buona correlazione con il gradiente medio calcolato al cateterismo

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Ao Vel AREA VALVOLARE Equazione di continuit LVOT area x LVOT Vel Area valvolare aortica = AVA = x r 2

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Non sempre si riesce a registrare bene la Velocit Massima (allineamento non corretto, finestra inadeguata, ecc) Posizionamento impreciso del volume campione del PW Doppler nel LVOT Misura approssimativa del diametro del LVOT nelle forme calcifiche e nelle marcate ipertrofie settali Assunto teorico: Forma circolare del LVOT. Profilo di flusso piatto nel LVOT I gradienti stimati al doppler sono flusso dipendenti: Incremento stroke volume: sepsi,anemia.. Diminuito stroke volume: disfunzione ventricolare sinistra Pitfalls

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Altri indici di severit Doppler velocity index Fractional shortening - velocity ratio Ejection fraction velocity ratio Resistenza valvolare aortica RVA Stroke work loss SWL Energy loss index ELI

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Doppler velocity index Rapporto tra la velocit nel TEVS misurata al doppler pulsato con la velocit transtenotica aortica misurata al doppler continuo LVOT TVI/ AV TVI < 0,25 suggerisce la presenza di stenosi aortica severa

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Ejection Fraction - Velocity Ratio E il semplice rapporto FE / gradiente massimo Doppler EFVR = Frazione di Eiezione / 4 x Vmax 2 Frazione di Eiezione VmaxGmaxEFVR 303.5490.61 503.5491.02 703.5491.43

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Severe aortic stenosis: Indication for AVR Symptomatic patients Patients with severe AS undergoing coronary artery bypass surgery, surgery of the ascending aorta, or on another valve Asymptomatic patients with severe AS and systolic LV dysfunction (LVEF,50%) unless due to othercause Severe aortic stenosis: Indication for AVR Symptomatic patients Patients with severe AS undergoing coronary artery bypass surgery, surgery of the ascending aorta, or on another valve Asymptomatic patients with severe AS and systolic LV dysfunction (LVEF,50%) unless due to othercause

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Aortic stenosis Should asymptomatic patients with severe aortic stenosis undergo to AVR ?

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Aortic stenosis Are asymptomatic patients with severe aortic stenosis really asymptomatic ?

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Test da sforzo Elettrocardiogramma: angina, dispnea, ipotensione, aritmie, sottolivellamento ST Ecocardiogramma: aumento del gradiente medio

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Severe aortic stenosis:Indication for AVR Asymptomatic patients with severe AS and abnormal exercise response Development of symptoms Development of hypotension Ic Severe aortic stenosis:Indication for AVR Asymptomatic patients with severe AS and abnormal exercise response Development of symptoms Development of hypotension Ic Severe aortic stenosis: Indication for AVR Asymptomatic patients with severe AS and abnormal exercise response Development of symptoms Development of hypotension IIB Severe aortic stenosis: Indication for AVR Asymptomatic patients with severe AS and abnormal exercise response Development of symptoms Development of hypotension IIB

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Aortic stenosis Should asymptomatic patients with severe AS undergo to AVR ? ..when they are really asymptomatic? Should asymptomatic patients with severe AS undergo to AVR ? ..when they are really asymptomatic?

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Severe aortic stenosis: Indication for AVR Asymptomatic patients with severe AS and moderate-to- severe valve calcification, and a rate of peak velocity progression 0.3 m/s per year IIa Severe aortic stenosis: Indication for AVR Asymptomatic patients with severe AS and moderate-to- severe valve calcification, and a rate of peak velocity progression 0.3 m/s per year IIa Severe aortic stenosis: Indication for AVR Asymptomatic patients with severe AS high likelihood of rapid progression (age, calcification e CAD) IIb Severe aortic stenosis: Indication for AVR Asymptomatic patients with severe AS high likelihood of rapid progression (age, calcification e CAD) IIb

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Stenosi aortica con ridotta funzione ventricolare sinistra Gradiente sistolico transvalvolare elevato Gradiente sistolico transvalvolare basso Disfunzione miocardica primitiva Disfunzione miocardica da afterload mismath Corretta valutazione della severit della stenosi ? Pseudostenosi Stenosi aortica vera

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Low dose dobutamine echocardiography Rationale Low dose dobutamine results in increased contactility Severe fixed AS: increased peak and mean velocity/gradient, non change in AVA Relative AS: no significant change in peak and mean velocity/gradient, significant increase in AVA or may be no contractile reverve no response to dobutamine : nothing changes ? ?

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Transthoracic echocardiography is recommended for re-evaluation of asymptomatic patients: - every year for severe AS; - every 1 to 2 years for moderate AS; - every 3 to 5 years for mild AS. Il follow-up